Provider Demographics
NPI:1073399200
Name:LANE, CORY ANDREW (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:ANDREW
Last Name:LANE
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 MISTWOOD FOREST DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-7029
Mailing Address - Country:US
Mailing Address - Phone:540-266-0453
Mailing Address - Fax:
Practice Address - Street 1:11455 PRINCE GEORGE DR
Practice Address - Street 2:
Practice Address - City:DISPUTANTA
Practice Address - State:VA
Practice Address - Zip Code:23842-6032
Practice Address - Country:US
Practice Address - Phone:111-070-7084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202010539235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist